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LATEST NEWS UPDATES | New Health Policy and Chronic Disease: Analysis of Data and Evidence -Subrata Mukherjee, Anoshua Chaudhuri, and Anamitra Barik

New Health Policy and Chronic Disease: Analysis of Data and Evidence -Subrata Mukherjee, Anoshua Chaudhuri, and Anamitra Barik

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published Published on Sep 12, 2015   modified Modified on Sep 12, 2015
-Economic and Political Weekly

The Ministry of Health and Family Welfare has made public the National Health Policy 2015 Draft for discussion. The draft is more exhaustive and better organised in its coverage compared to the National Health Policy of 2002. It touches upon contemporary issues of concern, including the rapid emergence of chronic non-communicable diseases. From the latest available evidence, issues crucial to tackling chronic illness in India are discussed.

Subrata Mukherjee (msubrata100@gmail.com) is at theInstitute of Development Studies, Kolkata. Anoshua Chaudhuri (anoshua@sfsu.edu) teaches Economics atSan Francisco State University, the US. Anamitra Barik (anomitro2010@gmail.com) is physician and research coordinator, Society for Health and Demographic Surveillance, West Bengal.

The Ministry of Health and Family Welfare, Government of India has placed the Draft National Health Policy (DNHP) 2015 in the public domain for comments, suggestions and feedback. One of the striking differences between this draft policy and the earlier National Health Policy 2002 is the former’s unambiguous observations on the emergence of non-communicable diseases (NCD), which consist of chronic diseases of a non-communicable nature. NCDs refer to medical conditions not caused by acute infections that have long-term consequences on individual health and require long-term treatment and care. NCDs have been recognised as an emerging global health challenge, particularly for its disproportionate impact on low- and middle-income countries (WHO 2014).

While communicable diseases are still responsible for 24.4% of the entire disease burden in India, DNHP 2015 observes that NCDs contribute to 39.1% of the country’s disease burden. It further takes a strong view that in various national health programmes, NCDs are very limited in coverage and scope, and comprehensive learning from various models of implementation is required.

This commentary is a brief review of the data and evidence available on chronic diseases in India. Presenting new evidence from a population-based survey, it also discusses the need for further generation of population-based as well as facility-level data.

Evidence on Chronic Disease

Emergence of chronic diseases is expected to impose a double burden on a country like India, which is still fighting communicable diseases. The most prominent chronic diseases include cardiovascular diseases, hypertension, diabetes, chronic respiratory illnesses, mental disorders and certain types of cancers. These diseases are most often under-reported and under-diagnosed, which makes them less visible than communicable diseases (Nugent 2008). The common factors attributed to the emergence of chronic diseases are demographic changes, urbanisation and lifestyle factors such as diet, exercise, as well as consumption of tobacco and alcohol (Nugent 2008; Upadhyay 2012). The earlier belief that chronic diseases are predominantly diseases of the rich and result from affluent lifestyles is no longer true (Prabhakaran et al 2013; Bhojani et al 2013). Most chronic diseases are equally prevalent in poor and rural populations (Patel et al 2011). Risk of chronic diseases such as cardiovascular diseases are higher among the poorer socio-economic classes (Xavier et al 2008). Chronic diseases are in fact highly inequitable with higher risk factors among lower socio-economic groups, and with more adverse financial implications for the poor in India (Thakur et al 2011). Malnutrition and infection in early life, a common occurrence amongst the poor, are found to increase the risk of chronic disease in later life (Bygbjerg 2012), creating even greater challenges for the poorer socio-economic groups.

The World Health Organization’s (WHO) Study on Global AGEing and Adult Health (SAGE) provides important estimates of chronic diseases for India based on a 2007–08 survey (Kowal et al 2012). The study found that 49% of Indian respondents aged 50 years and older reported at least one chronic condition. As expected, prevalence of most chronic disease increases with age, and women bear a disproportionately higher burden of chronic illnesses compared to men. The only exception is diabetes that has no clear age pattern, while a higher percentage of Indian men report diabetes compared to Indian women. Estimates from a five-location study suggest that chronic illness accounts for 18.5% of all reported illness episodes (Dror et al 2008). The most frequently mentioned chronic diseases were cardiovascular (21% of the chronic) musculoskeletal and connective tissue disorder (20%), chronic respiratory illnesses (9%) and diabetes mellitus (4%).

A statewide study of West Bengal by the Pratichi Institute (2012) found that chronic diseases account for more than 52% of the reported illnesses. Out of all the observed chronic diseases, arthralgia (joint pain without inflammation) was found to have the highest prevalence, and cardiovascular diseases, strokes and hypertension were top reasons for hospitalisation. Arthralgia/arthritis has been found to be more prevalent among the female population in rural areas compared to their urban counterparts.

Dror et al (2008) found that while chronic illnesses accounted for only 17.7% of reported illnesses, they accounted for 32% of total household expenditure on medical care. Macro-level estimates from developed countries show that even though costs of chronic disease range from 0.02% to 6.77% of household expenditure, when the indirect cost component (such as value of lost workdays and loss of earning ability) is considered, they are five times the direct costs of medical care. WHO estimates for India found that $336 billion of economic output were lost due to diabetes, stroke and cardiovascular diseases for 2005 (Nugent 2008).

Data in India

Current evidence on the prevalence of NCDs is mostly from micro studies of either non-population-based facility-level data published by the government or self-reported population-based survey data. Each have their own limitations in terms of lack of representativeness, completeness or systematic definitions of chronic diseases.

The National Health Profiles published by the Central Bureau of Health Intelligence provides data on the prevalence of select NCDs, such as coronary heart disease, diabetes and cancer. More detailed data on chronic illness may be available from the state departments of health. For example, an annual report titled Health on the March by West Bengal’s State Bureau of Health Intelligence provides number of cases and deaths (based on cases reported from hospital emergency departments) for major NCDs. Though this data is updated at regular intervals, one major limitation of facility-level data is the lack of adequate information to build a chronic disease profile of the population. This is mostly because at the facility-level, chronic diseases remain unreported and untreated, especially for the poor.

Four large-scale population surveys that have covered information on chronic illnesses in India are surveys by the National Sample Survey Office (NSSO), World Health Survey (WHS), WHO–SAGE Survey, and the National Family Health Survey (NFHS). The list of self-reported chronic conditions and illnesses covered by the NSSO in its 71st round (January–June 2014) is fairly exhaustive with a specific question on whether illness is chronic or not. The WHS for India, carried out in 2003, includes information on mobility, pain/ache of joint, back pain, cognition, vision, sleep/energy, depressive symptoms (feeling sad, low/depressed), arthritis, angina, chest pain, asthma, breathing trouble, and cervical cancer/breast cancer. The coverage of chronic illness in the latest available NFHS–4 (2015–16) includes individual measurements of bio-markers such as haemoglobin, blood sugar, blood pressure, human immunodeficiency virus (HIV), as well as self-reports of diabetes, asthma, hypertension, cancer and thyroid.

Evidence from HDSS–Birbhum

We now present new evidence on chronic illness from the Health and Demographic Surveillance System (HDSS) initiated in 2008 in Birbhum District by the Government of West Bengal. Birbhum, located in the western part of West Bengal, is one of the poorest districts in the state, which ranked 14 amongst 17 districts according to West Bengal Human Development Report 2004. A survey conducted in 2012 collected data on chronic illnesses as well as general morbidity, health consumption, and health expenditure at the household and individual level. The survey covered 54,585 individuals from 12,557 households residing in 351 villages from four administrative blocks of Birbhum, namely, Suri I, Md Bazar, Rajnagar and Sainthia. While four rural blocks were selected based on diversity in socio-economic profile, villages were selected by stratified random sampling from within the selected blocks. All households in selected villages were surveyed. The details of HDSS–Birbhum can be found in Ghosh et al (2014) and at http://www.shds.in.

The survey recorded the name of the illness/disease reported as well as up to five symptoms of the illness described by the respondent within a 30-day recall period. For each health episode, this information was analysed to assign a medical name to the illness. It was found that 10,491 sample individuals reported a total of 10,915 health episodes. Of these, 7,076 (65%) episodes were found to be acute illnesses, 75 (<1%) were communicable chronic illnesses, 2,309 (21%) episodes were in the category of chronic non-communicable illnesses, 416 (4%) episodes were accidents or injuries, and 918 (9%) episodes were either acute in nature or were an acute manifestation of a chronic disease and were therefore classified along with acute episodes. A total number of 36 episodes were not related to any illness as they were related to pregnancy and child birth, immunisation, and routine check-up. An acute illness in our analysis is one with a rapid onset and of a short duration. A chronic illness/condition on the other hand, is persistent, formed over a long period of time, and has long-lasting effects.

The prevalence of acute and chronic illness was examined for various socio-economic and demographic groups. The survey collected detailed information on consumption expenditure (both home-grown and purchased from the market) for each individual, which allowed us to use per capita consumption expenditure (PCCE) as a reasonable proxy for a household’s economic status. We used the 2011–12 poverty line for rural West Bengal (Rs 783), determined by the Planning Commission, to classify sample households into socio-economic groups (Government of India 2013). Households with PCCE less than Rs 783 were considered poor, those with PCCE equal to or higher than Rs 783 but lower than twice the poverty line (Rs 1,566) were considered lower-middle class, those with PCCE higher than Rs 1,566 but lower than four times the poverty line (Rs 3,132) were considered middle class, and those with PCCE equal to or higher than Rs 3,132 were considered upper-middle class/rich. The percentage of sample households belonging to poor, lower-middle, middle and upper-middle class/rich were 31.49%, 49.38%, 14.51% and 4.59%, respectively. This indicated that a majority of the sample households in Birbhum were lower-middle class or poor. Prevalence of chronic illness was also examined for differences by age and gender.

Select evidence on prevalence of acute and chronic illnesses and people’s utilisation patterns are presented in Tables 1, 2 and 3. It is not a surprise that the burden of acute illness is markedly higher than the burden of chronic illness if measured through prevalence. However, prevalence rates may not be the adequate measure to capture the real burden of chronic illness. Prevalence of chronic illness increases as we move from the poor to the rich—a pattern absent for acute illness. Even though there might be a higher proportion of elderly in the richer groups (due to longer life expectancy), such a sharp increase in chronic illness amongst richer groups is a clear indication of under-reporting of chronic illness amongst poorer groups.

Data also indicates consistently lower health utilisation, both as outpatient and inpatient, for chronic illnesses compared to acute illnesses. Utilisation of outpatient healthcare for both chronic and acute episodes shows a declining dependence on government facilities (Table 2). What is disturbing is that a large percentage of chronic illnesses remains untreated for the poor. Treatment when provided in the outpatient, is mostly through other sources which dominantly includes unqualified medical practitioners. Evidence also points to lower rates of hospitalisation for chronic illness amongst the poor compared to higher-income groups (Table 3). The socio-economic gradient for chronic-illness-related hospitalisation is steeper than acute-illness-related hospitalisation. There is a disproportionate rise in chronic-care-related hospitalisation in government hospitals among the rich, suggesting that the poor either have lower utilisation or lower access (or both) to government hospitals.

Discussion

The increasing emergence of chronic diseases in India calls for a comprehensive public health response that can effectively address all issues relevant to chronic diseases, touching upon both socio-economic and medical aspects. Poverty and chronic disease seem to be inextricably linked—many chronic illnesses could be the result of early-life malnutrition. Evidence shows that to have an impact on the burden of chronic diseases, interventions must occur at three levels, namely, household/individual level, community level, and at the health-service level, which include both preventive services and appropriate care for persons with chronic conditions. The interventions which can modify behavioural risk factors (such as diet, physical activity and exercise, consumption of tobacco and alcohol) through policy, public education, or a combination of both can be effective in reducing the prevalence of many chronic diseases.

Policy interventions can also be effective in reducing the levels of several major biological risk factors linked to chronic diseases (high blood pressure, overweight and obesity, diabetes, and abnormal blood cholesterol). Though the evidence for health promotion and primary prevention are weaker, policy interventions and secondary prevention, when combined, are likely to have a greater impact on reducing national chronic disease burden (Singh, Reddy and Prabhakaran 2011). DNHP 2015 proposes to support an integrated approach, where primary screening for the most prevalent chronic diseases, along with secondary prevention that would reduce morbidity and preventable mortality, would be incorporated into the comprehensive primary healthcare network.

More evidence on effectiveness of this kind of integration is necessary as it is important to have good quality data both at the population and facility level on chronic disease prevalence, access and cost of treatment. We need this evidence from various contexts and for various demographic groups. Our results show that for the rural poor, in particular, acute illnesses are not only more prevalent (perhaps reported more) but also that these receive greater treatment than chronic illnesses.

There is further evidence of a steep socio-economic gradient in the utilisation of care for chronic illnesses, particularly at the inpatient level. A comparison between the last two NSS rounds (52nd and 60th) clearly points to rural population’s increasing dependence on private healthcare providers for both outpatient and inpatient care (NSSO 1998, 2006). Much of the public health networks in rural areas are better equipped to provide treatment for acute illnesses, or reproductive and child health needs. Therefore, to get the right kind of care for a chronic illness, one has to travel to secondary or tertiary hospitals located in sub-divisions or district headquarters, or in big cities. Consequently, treatment of chronic illness becomes relatively much more expensive. Chronic healthcare, if mostly provided by the private sector, can be expensive and unaffordable to many. A wide range of cost-effective primary and secondary prevention strategies for chronic diseases are available, but their coverage is found to be low among the poor and rural populations (Patel et al 2011). Integrating different national programmes for various chronic diseases as well as acute communicable diseases along with various preventive strategies at the primary level for the rural poor could be a practical way to deal with the problem of access to care for chronic conditions.

More evidence is required from facility-level data on detection of acute-chronic co-morbidity. This has crucial policy implications. For example, when a patient visits a health facility for a particular acute illness, does his/her chronic condition get detected and taken care of at that point? DNHP 2015 makes a crucial point that care for select chronic illnesses be firmly linked through continuity of care arrangements with specialists’ consultations, initiated and then followed up at the primary-care level. The existing national programmes (and may be new ones) can play a crucial role by ensuring necessary resources and capacity support for building up an integrated approach at the district level. The new Ministry ofAyush can help integrate programmes at the primary level that would alleviate supply-side constraints by providing legitimate alternative medical advice, which would help in managing chronic conditions, and prevent costly referrals to tertiary hospitals.

Finally, there is an important demographic and gender dimension to the prevalence of chronic illness. Chronic illnesses most commonly afflict the elderly, who are mostly non-earning members of the household. As a result of higher life expectancy and large spousal-age gaps at marriage, elderly women tend to live longer with these chronic ailments. With limited resources that can be spent on healthcare, it is likely that not only is there a crowding-out of treatments for chronic illnesses, but also when households ration the amount they spend on chronic diseases, especially in poor households, the individuals facing such rationing are mostly the elderly, and elderly women.

Conclusions

To foster a deeper discussion on policy to tackle the rapidly emerging problems around chronic disease, we provide a summary of rather limited evidence on chronic disease in India. It is clear that there is severe under-reporting and under-treatment of chronic diseases among the rural poor. Reasons could be demand constraints due to lack of adequate income as well as supply-side constraints of support infrastructure. There is an urgent need for regular generation of population-based as well as facility-level data on chronic diseases to design effective strategies to address chronic disease.

References

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Bygbjerg, I C (2012): “Double Burden of Noncommunicable and Infectious Diseases in Developing Countries,” Science, Vol 337, No 6101, pp 1499–1501.

Dror, D M, O van Putten-Rademaker and R Koren (2008): “Cost of Illness: Evidence from a Study of Five Resource-poor Locations in India,” Indian Journal of Medical Research, Vol 127, No 4, 347–61.

Ghosh, S et al (2014): “Health & Demographic Surveillance System Profile: The Birbhum Population Project (Birbhum HDSS),” International Journal of Epidemiology, doi: 10.1093/ije/dyu228.

Government of India (2013): Press Note on Poverty Estimates, 2011–12, Planning Commission, http://planningcommission.nic.in/news/press_pov2307.pdf, viewed on 7 July 2015.

Kowal, P, S Williams, Y Jiang, W Fan, P Arokiasamy and S Chatterji (2012): “Ageing, Health and Chronic Conditions in China and India: Results from the Multinational Study on Global AGEing and Adult Health (SAGE),” Ageing in Asia: Findings from New and Emerging Data Initiatives, J P Smith and M Majmundar (eds), Washington DC: National Academies Press.

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Patel, V, S Chatterji, D Chisholm, S Ebrahim, G Gopalkrishna, C Mathers, V Mohan, D Prabhakaran, R D Ravindran and K S Reddy (2011): “Chronic Diseases and Injuries in India,” Lancet, Vol 377, No 9763, pp 413–28.

Pratichi Institute (2012): Non-communicable Diseases: A Preview from West Bengal, A study by Pratichi Institute.

Prabhakaran, D, P Jeemon and K S Reddy (2013): “Commentary: Poverty and Cardiovascular Disease in India: Do We Need More Evidence for Action?”, International Journal of Epidemiology, Vol 42, No 5, pp 1431–35.

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Thakur, J S, Shankar Prinja, Charu C Garg, Shanthi Mendia and Nata Menabde (2011): “Social and Economic Implications of Noncommunicable Diseases in India,” Indian Journal of Community Medicine, Vol 36, No 5, Suppl 1, pp 13–22.

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Economic and Political Weekly, Vol-L, No. 37, September 12, 2015, http://www.epw.in/commentary/new-health-policy-and-chronic-disease.html


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